New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 56 - MANUAL FOR DENTAL SERVICES
Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS)
Section 10:56-3.2 - D0100-D0999 DIAGNOSTIC
Current through Register Vol. 56, No. 18, September 16, 2024
(a) Clinical Oral Examination:
Maximum Fee | ||||||
HCPCS | Allowance | |||||
IND | Code | Mod | Procedure Description | S | $ | NS |
D0150 | Comprehensive oral evaluation | 15.00 | 14.00 |
NOTE 1: This code is to be used for comprehensive clinical oral evaluation of a Medicaid/NJ FamilyCare fee-for-service beneficiary.
NOTE 2: This code requires a thorough observation of all conditions present in the oral cavity and contiguous structures to include:
NOTE 3: For reimbursement of the comprehensive oral evaluation with code D0150:
D0150 | 76 | Comprehensive oral evaluation | 14.00 | 13.00 |
NOTE 1: This code is to be used only if a beneficiary is developmentally disabled or neurologically impaired (see 10:56-2.9(a)1 ii), in which case an examination may be provided as often as every three months and may be submitted directly to the fiscal agent for payment without prior authorization. The nature of the beneficiary's disability must be recorded under "Remarks" on the Dental Services Claim form (MC-10).
D0150 | EP | Comprehensive oral evaluation | 25.00 | 21.00 |
NOTE 1:
NOTE 2: This code requires a thorough observation of all conditions present in the oral cavity and contiguous structures to include:
NOTE 3: For reimbursement of the comprehensive oral evaluation with code D0150 EP:
D0120 | Periodic Oral Evaluation | 15.00 | 14.00 |
NOTE: An evaluation performed on a patient of record to determine any changes in the patient's oral health status since a previous initial or periodic examination.
D0120 | EP | Periodic Oral Evaluation | 15.00 | 14.00 |
NOTE: This code is to be used with an EPSDT referral on a patient of record to determine any changes in the patient's oral health status since a previous initial or periodic examination.
d | D0140 | Limited oral evaluation | 4.00 | 3.00 |
NOTE: Make note of diagnosis and/or observation(s) on the Dental Services Claim form (MC-10).
D0160 | Detailed and extensive oral | 14.00 | 13.00 |
evaluation problem focused by | |||
report. | |||
D0170 | Re-evaluation--limited, problem | 14.00 | 13.00 |
focused (Established patient; not | |||
post-operative visit) |
(b) Radiographs:
Maximum Fee | ||||||
HCPCS | Allowance | |||||
IND | Code | Mod | Procedure Description | S | $ | NS |
D0210 | 52 | Intraoral-Complete Series | 18.00 | 18.00 |
NOTE 1: Limited to patients up to and including age six.
NOTE 2: Eight films.
D0210 | Intraoral--Complete Series | 22.00 | 22.00 |
(including bitewings) |
NOTE 1: Limited to patients age seven up to and including age 14.
NOTE 2: Twelve films.
D0210 | 22 | Intraoral--Complete Series | 26.00 | 26.00 |
(including bitewings) |
NOTE 1: Limited to patients age 15 or older.
NOTE 2: Minimum of 16 films.
D0220 | Intraoral--Periapical--First Film | 3.75 | 3.75 |
D0230 | Intraoral--Periapical--Each | 2.75 | 2.75 |
Additional Film |
NOTE 1: Indicate complete number of films (D0220 Plus D0230) in item 13.
D0240 | Intraoral--Occlusal Film | 5.00 | 5.00 |
NOTE 1: Per film (maximum--two films).
NOTE 2: Indicate number of films in item 13.
D0250 | Extraoral, First Film | 10.00 | 10.00 |
NOTE: Code to be used for lateral, anteroposterior, temporo-mandibular radiographs, etc. (one view).
D0260 | Extraoral-- | 5.00 | 5.00 |
Each Additi | |||
onal Film |
NOTE 1: Indicate number of views in item 13.
NOTE 2: Maximum reimbursable--two additional views.
D0270 | Bitewing--Single film | 3.00 | 3.00 | |
D0272 | Bitewings--Two films | 5.00 | 5.00 | |
D0274 | Bitewings--Four films | 9.00 | 9.00 | |
D0290 | Posterior--anterior or lateral | 10.00 | 10.00 | |
skull and facial bone survey film | ||||
D0310 | Sialography | 15.00 | 15.00 | |
D0310 | 22 | Sialography | 30.00 | 30.00 |
NOTE: Includes injection of contrast material (filling and/or emptying phases).
D0320 | Temporomandibular joint | 30.00 | 30.00 | |
anthrogram, including injection | ||||
D0321 | Other temporomandibular joint | BR | BR | |
films, by report | ||||
D0322 | Tomographic survey | 125.00 | 90.00 | |
D0330 | Panoramic Film | 15.75 | 15.75 | |
D0340 | Cephalometric Film | 15.00 | 15.00 | |
D0340 | 22 | Cephalometric Film | 22.50 | 22.50 |
NOTE: Includes tracing.
(c) Test and laboratory examinations:
D0470 | Diagnostic Casts | 11.50 | 10.00 |
NOTE 1: Casts must have bases and be trimmed to permit articulation, per cast.
NOTE 2: Code not to be used in conjunction with denture construction.
D0472 | Accession of tissue, gross | 9.35 | 9.35 |
examination, preparation and | |||
transmission of written report | |||
D0473 | Accession of tissue, gross and | 20.85 | 20.85 |
microscopic examination, | |||
preparation and transmission of | |||
written report | |||
D0474 | Accession of tissue, gross and | 40.00 | 40.00 |
microscopic examination, including | |||
assessment of surgical margins for | |||
presence of disease, preparation | |||
and transmission of written report | |||
D0480 | Processing and interpretation of | 12.00 | 12.00 |
cytologic smears, including the | |||
preparation and transmission of | |||
written report | |||
D0350 | Oral/facial images (includes intra | 1.00 | 1.00 |
and extraoral images) |
NOTE: Or slides, per view.
d | D0501 | Histopathologic Examination | 10.00 | 10.00 |
NOTE 1: The gross and microscopic examination of oral tissues, both hard and soft.
NOTE 2: Limited to specialists in oral pathology, and Oral Diagnosis (Pathology) Departments of dental schools.
D0502 | Other oral pathology procedures, | BR | BR | |
by report | ||||
d* | D0999 | Unspecified Diagnostic Procedure, | BR | BR |
By Report |
NOTE: Complete description of procedure and the reason the procedure was performed.